Cerebrovascular Disease

Ji Y. Chong

Description

Patients suffering from cerebrovascular disease pose many clinical challenges and even experienced clinicians can arrive at the point where diagnostic, work-up, treatment, or prognostic thinking falters.

Authored by a vascular neurologist whose work spans the entire spectrum of this group of brain dysfunctions, Cerebrovascular Disease helps clinicians evaluate and manage patients suffering from stroke, embolism, thrombosis, hemorrhage, and other critical presentations. In a medical field where it's often difficult to distill the vast array of research and apply it in any meaningful clinical way, this next volume in the "What Do I Do Now?" series focuses on walking the clinician through evidence-based decision-making. Each clinical scenario featured in
Cerebrovascular Disease describes in careful detail the presentation, diagnostic studies, treatment options, and rationale for handling these tricky cases.

Cerebrovascular Disease

Ji Y. Chong

Table of Contents

Table of Contents

Case 1 IV tPA for acute ischemic strokeIV tPA is the only FDA approved treatment for acute ischemic stroke. It needs to be delivered in a timely fashion, but select patients may be treated beyond the 3 hour window out to 4 and a half hours.

Case 2 Endovascular treatment for acute ischemic strokeSelect patients who are not eligible for IV tPA and are within an 8 hour window may be treated with other acute endovascular therapies.

Case 3 Combination reperfusion therapy for acute strokeIn patients who do not recanalize with IV tPA, adjunctive endovascular therapies may be used to improve reperfusion.

Case 4 Hemorrhagic complications of tPAIntracerebral hemorrhage is a known complication of tPA.
Different hemostatic agents can be used for symptomatic hemorrhage.

Case 5 Stroke mimic and acute treatmentPatients with stroke mimics and eligible for tPA may safely be treated. The diagnosis of a stroke mimic is typically made after the acute setting.

Case 6 Minor stroke symptoms and acute treatmentPatients with minor stroke symptoms or rapid improvement of symptoms are at high risk of worsening. Acute treatment with IV tPA may be warranted.

Case 7 Hemicraniectomy for large MCA strokeMalignant MCA syndromes have high morbidity and mortality. Hemicraniectomy in select patients is life saving but patients often have significant disability.

Case 9 Blood pressure management in acute strokeBlood pressure is commonly elevated after a stroke. Early lowering of blood pressure may worsen outcomes.

Case 10 Primary prevention of strokeScreening for risk factors and treatment of modifiable risk factors will lower the risk of incident stroke.

Case 11 Asymptomatic carotid stenosisRevascularization of high grade asymptomatic carotid stenosis in select patients can lower the risk of incident stroke. Endarterectomy and stenting are both associated with periprocedural risk.

Case 12 Secondary stroke prevention after lacunar strokeLong term blood pressure management is important
after lacunar stroke. Antiplatelet therapy should be instituted for secondary stroke prevention.

Case 14 Secondary stroke prevention after stroke due to intracranial atherosclerosisMedical therapy with antiplatelet therapy and aggressive risk factor control is the preferred treatment regimen for stroke prevention in patients with intracranial atherosclerosis.

Case 16 Secondary stroke prevention after cryptogenic stroke with PFOMedical therapy for patients with stroke and PFO include antiplatelet therapy or anticoagulation. PFO closure is not routinely recommended for stroke prevention.

Case 17 Carotid dissectonCarotid dissection can be recognized by exam findings and radiographic studies. Treatment can include aspirin or anticoagulation.

Case 18 Stroke in a young adultTraditional vascular risk factors can contribute to stroke in young adults. Other more unusual causes of stroke should be considered based on the clinical setting.

Case 27 Intracerebral hemorrhage secondary to AVMAVMs may cause intracerebral hemorrhage. Treatment can be challenging and multimodal treatment is often required

Case 28 Cavernous malformationCavernous malformations may cause intracerebral
hemorrhage and seizures. Surgical resection is considered in patients with accessible lesions and recurrent hemorrhage or refractory seizures.

Case 29 Aneurysmal subarachnoid hemorrhageDiagnosis is made by CT scan in most cases, but lumbar puncture may be needed if CT findings are normal. Rapid evaluation and treatment are important because of the high morbidity and mortality.

Case 30 Perimesencephalic SAHPerimesencephalic SAH is a more benign subset of SAH. Evaluation for aneurysm is obligatory.

Case 31 Asymptomatic intracranial aneurysmLocation and size of an intracranial aneurysm are helpful in stratifying risk of hemorrhage. Treatment may be observation, surgical clipping, or endovascular coiling.

Cerebrovascular Disease

Ji Y. Chong

Reviews and Awards

"I am impressed with the unique format of case reports that are each instructive of a clinical lesson, including modern brain imaging and intravascular approaches to diagnosis and treatment of brain lesions. The numerous figures are ample, clear, and helpful. This little book will find its way in to the pockets of residents everywhere." -- Lewis P. Rowland MD, Neurological Institute, Columbia University Medical Center, New York, NY

"Dr. Chong's book provides a thorough review of Vascular Neurology, all presented through a series of quickly digested real-life cases. Each case illustrates a common stroke-related diagnostic or treatment situation, and provides insight into the approach of an experienced clinician. The rationale for decision-making is fully justified by the available evidence base where data exist, and by sophisticated reasoning in the gray areas where there are no data. Novices will appreciate the fundamentals of stroke neurology, but even experts will find new tidbits of information in this easy to read but comprehensive book." -- Mitchell S. V. Elkind, MD, MS, FAAN, FAHA, Fellowships Director, Department of Neurology, Columbia University, New York, NY

"Ji Chong has put together this terrific book that instructs us one case at a time about many of the evidence-based approaches to manage our stroke patients...The innovative approach in this book of weaving together the careful patient histories, illustrative brain images, and other diagnostic images with insightful commentaries is a great way to learn about the latest approaches to stroke management. Each case makes many teaching points and paints a picture to help us care for countless other patients in our daily pursuit to reduce the consequences of stroke." -- Ralph L Sacco, MD, Chairman of Neurology, Executive Director, Evelyn McKnight Brain Institute, Olemberg Family Chair in Neurological Disorders, Miller Professor of Neurology, Epidemiology & Public Health, Human
Genetics, and Neurosurgery, Chief of Neurology, Jackson Memorial Hospital, Miller School of Medicine, University of Miami, FL